Reviewing Efforts to Replace the Affordable Care Act

Over 45 million individuals receive health insurance only because of the Patient and Protection Affordable Care Act (ACA). As the ACA approaches its fifteenth anniversary, the statute will likely face opposition from the Trump Administration. A recent leak of potential cuts to federal health care financing underscores the increasing importance of understanding where the ACA is most vulnerable.

In a November post on Truth Social, President-Elect Donald Trump promised to replace the ACA with “much better health care.” As ACA proponents prepare for the Trump Administration and a Republican majority in both houses of the U.S. Congress, a review of past proposals to repeal the ACA may reveal insights into what lies ahead.

Enacted in 2010, the ACA was designed to “make affordable health insurance available to more people,” providing states with the option to expand their Medicaid programs to cover low income adults and facilitating “innovative medical care delivery methods” to decrease the cost of health care. To date, 40 states, as well as the District of Columbia, have adopted Medicaid expansion, providing coverage to an additional 24 million people.

To increase access to affordable coverage, the ACA introduced an “individual mandate,” which mandated that people must “obtain health insurance or pay a tax penalty.” Health insurance plans that comply with the individual mandate must provide  “minimum essential coverage” to policyholders and their dependents, including certain preventive services, regardless of any pre-existing conditions.

To ease access to plans that comply with the ACA’s consumer protections, the ACA created marketplaces, which are state or federal government-operated websites that provide a “one-stop shopping experience” for consumers to enroll in federally subsidized coverage that reduces the monthly cost of health insurance for people at certain low incomes.

Since it was passed, Republican lawmakers have attempted to repeal the ACA more than 50 times.

Efforts to repeal or replace the ACA peaked in 2017. At the start of his first presidency, President Trump issued an executive order stating the intent of his Administration “to seek the prompt repeal” of the ACA.

During President Donald Trump’s first year in office, conservative members of Congress introduced, among others, five proposals designed to repeal or replace the ACA: the Better Care Reconciliation Act, American Health Care Act of 2017, Obamacare Repeal Reconciliation Act of 2017, Health Care Freedom Act, and the Graham-Cassidy-Heller-Johnson Amendment.

A review of these proposals reveals several themes.

First, all five proposals would have repealed the ACA’s individual mandate, even though the tax penalty for noncompliance was zeroed out by Congress in 2019.

All five of the proposals would have repealed provisions of the ACA that expanded financial assistance available to consumers with low incomes.

All of the proposals targeted the ACA’s Medicaid expansion provisions. For example, the Better Care Reconciliation Act, proposed in July 2017, would have gradually reduced the amount of federal funds available for states to expand their Medicaid programs, “restoring levels of federal support to preexisting law” in the name of “fairness for non-expansion states.”

Proposals to undermine the ACA also would have increased access to “junk insurance” or “subpar plans”—health insurance plans that do not comply with the ACA’s protections. For example, these plans may allow insurers to discriminate based on pre-existing health conditions or fail to provide comprehensive coverage for health emergencies. President Trump endorsed subpar plans in an October 2017 executive order, as legislative efforts to repeal and replace the ACA were losing public support.

For example, the Better Care Reconciliation Act would have expanded access to “small business health plans,” which are group health plans sold by health insurers that are not subject to the ACA’s limits on adjusting premiums based on factors such as health status and requirements to provide certain “essential health benefits.” These plans would have given insurers that offer ACA-compliant coverage on marketplaces the option to sell other plans outside of the marketplace that are not ACA-compliant.

ACA repeal proposals also reflect an emphasis on shifting responsibility to states to finance and administer health care delivery. The Congressional Budget Office estimated that the American Health Care Act of 2017 would have reduced Medicaid spending by over $880 billion between 2017 and 2026.

To counterbalance the reduction in federal Medicaid spending, the American Health Care Act would have established a Patient and State Stability Fund, which would have pooled $100 billion over nine years, creating a funding source that states could apply for and have flexibility to allocate toward health care delivery.

Despite President Trump’s initial call for the “prompt repeal” of the ACA, none of the legislative proposals we reviewed would have repealed the Act altogether. In fact, all of these proposals would have retained some elements of the ACA.

Many proposals would have retained the ACA’s rules for coverage sold on private marketplaces.

For example, the Obamacare Repeal Reconciliation Act of 2017 would have preserved marketplace requirements for covering essential health benefits and the prohibition against excluding because of pre-existing conditions. The Health Care Freedom Act would have retained open and special enrollment periods for health insurance marketplaces.

Despite being a “top legislative priority” of conservative policymakers, the repeal and replace proposals failed to pass. Only 17 percent of Americans and about 40 percent of Republicans polled supported these efforts. Notably, KFF found that by June 2017, most Americans viewed the ACA more favorably than the proposed plans that would replace it.

The proposals we reviewed mapped onto President Trump’s executive orders at the time, reflecting an attempt to make a concerted effort against the ACA across branches of government that are likely to continue in President Trump’s second term. Although efforts to mobilize in opposition were unsuccessful, proposals to cut funding from and reform the structure of programs under the ACA have already emerged and reflect the intention of the Trump Administration to undercut the status quo of health care administration.

As ACA advocates look ahead, they should understand past repeal and replace efforts to bolster a defense against these measures. Looking at what previous policymakers would have left of the ACA may also provide insight into where there is common ground to retain elements of the ACA’s protections until the next election.